Download Standard OTR Form - Search for MHNet Providers

Outpatient Treatment Report
Provider Name & License/Certification Type
(Please Print):
6588
Member Name (Please Print):
___________________________________________
_________________________________________
NPI:
Member ID #:
Tax ID #:
/
DOB:
CPT Codes Requested
Numeric Code-Modifier
/
Diagnoses
Axis II:
Axis I:
.
Axis I:
GAF:
.
Axis III:
.
CPT:
Sometimes-
CPT:
-
Check box if member has been
previously hospitalized.
.
Axis IV:__________________________
List Medications Below:
______________________
______________________
______________________
Check box if member is
pregnant.
Provider Signature:_________________________________
Date Signed:
FUNCTIONAL IMPAIRMENT RATING SCALE
Fill in the bubble like this
of impairment in each domain.
Medications
Anti-depressant
Anti-psychotic
Anti-anxiety
Mood Stabilizer
Sleep Aid
ADHD Medication
Other
to indicate current level
/
CURRENT LEVEL OF IMPAIRMENT
None
Moderate
Affective
Depression, mania, mood instability, inappropriate mood
Anxiety
Panic, worry, anxiety, easily startled, flashbacks, nightmares
ADHD Symptoms
Hyperactivity, impulsivity, poor insight, poor judgment
Obsessions & Compulsions
Rituals, fear of contamination, excessive need for orderliness, hair
pulling, unacceptable impulses
Reality Construction & Thought processes
Delusions, hallucinations, disorganized or racing thoughts,
dissociative states, paranoia
Cognitive
Cognitive impairments due to organic conditions including brain
trauma, dementia and mental retardation
Social
Difficulty forming positive relationships, social isolation,
anger/aggression, interpersonal problems at work/school
Substance Abuse
Problematic use of drugs or alcohol
Harm to Self or Other
Suicidal ideation, intentionally self injurious behavior, suicide
planning, danger to others
Appetite & Eating
Disturbances in appetite, anorexia or bulimia
Sleep
Disturbances in sleep patterns, including excessive sleep
Other Medical Conditions
Presence of medical conditions which have significant impact on
patient functioning and/or quality of life
500
Fax Completed Forms To: 877-675-7421
Provider Secure Fax #:
(Required)
/
State:
(Required)
Severe